306005272-5-15-2026-22-AS-AORZ-DU9VN6-20260520163437

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005272
Report Date: 05/15/2026
Date Signed: 05/15/2026 03:47:25 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/20/2026 and conducted by Evaluator Fred Arias

COMPLAINT CONTROL NUMBER: 22-AS-20260320094728

FACILITY NAME:	PACIFICA SENIOR LIVING SOUTH COAST		FACILITY NUMBER:	306005272
ADMINISTRATOR:	YAYLENE MAZARIEGOS		FACILITY TYPE:	740
ADDRESS:	2619 ORANGE AVE		TELEPHONE:	(949) 515-0121
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92627
CAPACITY:	98	CENSUS: 71	DATE:	05/15/2026
		UNANNOUNCED	TIME BEGAN:	01:26 PM
MET WITH:	Adriana Mendoza		TIME COMPLETED:	04:01 PM

ALLEGATION(S):

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Facility did not bring the change in cognitive functions to the resident’s physician.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Fred Arias conducted an unannounced complaint visit to finalize an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit.

It was alleged facility did not bring the change in cognitive functions to the resident’s physician. During the investigation, LPA conducted interviews with staff and resident in care. LPA reviewed records obtained.

The investigation determined as follows: Regarding the allegation facility did not bring the change in cognitive functions to the resident’s physician, it was reported the facility did not seek an updated physician’s report for Resident (R1) with a current diagnosis. Interview with R1 stated they have seen their primary care physician (PCP) a couple of times since their readmission to the facility on February 27, 2026.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 22-AS-20260320094728

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PACIFICA SENIOR LIVING SOUTH COAST	FACILITY NUMBER: 306005272
	VISIT DATE: 05/15/2026

NARRATIVE

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Interview with Administrator (AD) Yaylene Mazariegos stated upon R1’s readmission from the skilled nursing facility (SNF), R1’s PCP was present at the facility and administered a new exam for R1. AD added R1 arrived at the facility with a physician’s report provided by the SNF. LPA reviewed R1’s file and confirmed there was an updated physician's report signed by the PCP on March 6, 2026 with an examination date of February 27, 2026. The physician’s report did not indicate a diagnosis of dementia. LPA reviewed a prior physician's report dated also on February 27, 2026 with a diagnosis of dementia for R1. However, the physician’s report was not signed by a licensed medical professional and therefore not valid.

Based on interviews and record review, LPA is unable to corroborate the allegation. Therefore, the allegation is deemed to be UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted and a copy of the report was left with the facility representative.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/20/2026 and conducted by Evaluator Fred Arias

COMPLAINT CONTROL NUMBER: 22-AS-20260320094728

FACILITY NAME:	PACIFICA SENIOR LIVING SOUTH COAST		FACILITY NUMBER:	306005272
ADMINISTRATOR:	YAYLENE MAZARIEGOS		FACILITY TYPE:	740
ADDRESS:	2619 ORANGE AVE		TELEPHONE:	(949) 515-0121
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92627
CAPACITY:	98	CENSUS: 71	DATE:	05/15/2026
		UNANNOUNCED	TIME BEGAN:	01:26 PM
MET WITH:	Adriana Mendoza		TIME COMPLETED:	04:01 PM

ALLEGATION(S):

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Facility staff did not answer calls promptly from resident's representative.
The resident's call button is in disrepair.
The facility vehicle is in disrepair.
There is insufficient staff to support the needs of the resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Fred Arias conducted an unannounced complaint visit to finalize an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit.

It was alleged facility staff did not answer calls promptly from resident's representative, the resident's call button is in disrepair, the facility vehicle is in disrepair and there is insufficient staff to support the needs of the resident . During the investigation, LPA conducted interviews with witness, staff and residents in care. LPA reviewed records obtained.

The investigation determined as follows: Regarding the allegation facility staff did not answer calls promptly from resident's representative, it was reported R1’s representative contacted the Administrator (AD) Yaylene Mazariegos on several occasions but calls were not returned. Interview with Witness 1 (W1) stated they’ve attempted to contact AD Yaylene Mazariegos on different occasions but it has been challenging as AD has been out of the office.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 22-AS-20260320094728

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PACIFICA SENIOR LIVING SOUTH COAST	FACILITY NUMBER: 306005272
	VISIT DATE: 05/15/2026

NARRATIVE

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W1 stated they have been assisted by other staff with billing questions when AD is not available. Interview with AD stated she has not received calls from W1 recently. AD provided LPA with copies of her call log indicating last phone contact with W1 on June 30, 2025 via voicemail. AD added she has spoken with W1 in person on several occasions when they come to the facility to visit R1.

Regarding the allegation the resident's call button is in disrepair, it was reported the call button in R1’s room is not working. Interview with R1 stated they are able to call for assistance by pulling on cord with call buttons located by the bed or in the bathroom. Two out of three other residents interviewed stated they have used the pull cord in the past and have had staff respond. The remaining resident stated they have never used the pull cord in their room. LPA pulled the cord in R1’s room and a staff member responded within 14 minutes.

Regarding the allegation vehicle is in disrepair, it was reported the facility vehicle is not operational to assist residents with transportation. Interviews with one out of four residents stated the facility vehicle has been operational since November 2025 but was not in use February 2026 due to maintenance and repairs. The remaining three residents stated they have not had to use the facility vehicle for their transportation needs. Interviews with one out of six staff stated the vehicle was not available for three weeks in February 2026 as it needed have the wheelchair ramp repaired but has been operational since. The remaining five staff did not add anything relevant to the allegation. Interview with AD stated the facility vehicle was going through maintenance and repairs recently. AD added the facility was providing transportation for residents using Uber while the vehicle was being serviced. Record review revealed the facility vehicle had gone through recent maintenance and service including the repair of the wheelchair ramp February 2026. AD provided the transportation log for March 2026 including scheduled doctor appointments for residents. LPA along with staff observed the facility vehicle in operation. LPA did not observe the vehicle in disrepair.

Regarding the allegation there is insufficient staff to support the needs of the resident, it was reported there are no drivers available to transport residents to their appointments. One out of five residents stated the facility has assisted with arranging for transportation using Uber. The resident added the facility covered the cost. Three out of the remaining four residents stated they have never needed to arrange transportation with the facility. The remaining resident did not add anything relevant to the allegation. LPA interview with one out of six staff stated they are a driver for the facility vehicle. The staff member showed LPA their driver’s license which is valid.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 22-AS-20260320094728

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PACIFICA SENIOR LIVING SOUTH COAST	FACILITY NUMBER: 306005272
	VISIT DATE: 05/15/2026

NARRATIVE

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The facility vehicle is a 12 passenger vehicle. A “P” (passenger) endorsement is required by the Department of Motor Vehicles to operate the vehicle. The staff member’s driver’s license does not indicate a P endorsement has been obtained. The remaining staff did not add anything relevant to the allegation. Interview with AD stated there are two facility drivers but neither has a P endorsement on their driver’s license. There are no staff qualified to drive the facility vehicle. AD added arrangements have also been made for transportation using Uber and medical transport companies Blue Riven and Garden Grove Bus for non-ambulatory residents. The cost of transport is covered by the facility. Record review revealed resident admission agreements include a transportation policy that states “We will make available to residents, or otherwise assure the provision of, scheduled transportation to the nearest appropriate health facilities for medical and dental appointments, social services agencies, shopping and recreational facilities within a ten (10) mile radius of the community.” The facility plan of operations states “Plan, arrange and/or provide for transportation to medical and dental appointments. Facility will assist with making arrangements for transportation to and from medical and dental services” as part of their basic services offered.

Based on interviews, record review, and observations, the allegations of facility staff did not answer calls promptly from resident's representative, the resident's call button is in disrepair, the facility vehicle is in disrepair and there is insufficient staff to support the needs of the resident are therefore deemed unsubstantiated meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

An exit interview was conducted and a copy of the report was left with the facility representative.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026

LIC9099 (FAS) - (06/04)

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